Provider Demographics
NPI:1083822027
Name:COUGHLIN, SANDRA MARY (NNP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:MARY
Last Name:COUGHLIN
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33-57 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2107
Mailing Address - Country:US
Mailing Address - Phone:315-470-7009
Mailing Address - Fax:315-470-2923
Practice Address - Street 1:33-57 HARRISON ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2107
Practice Address - Country:US
Practice Address - Phone:315-470-7009
Practice Address - Fax:315-470-2923
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF-350220-1163WN0002X
NYF-350220363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF350220-1OtherLICENSE